Provider Demographics
NPI:1013025097
Name:JORDAN-WAGNER, DIANE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JORDAN-WAGNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-232-0564
Mailing Address - Fax:812-235-3330
Practice Address - Street 1:1429 N 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-1037
Practice Address - Country:US
Practice Address - Phone:812-232-0564
Practice Address - Fax:812-235-3330
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056292A207RA0201X
IL36106006207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
030005377OtherRAILROAD MCARE PALAMETTO
IN200392780Medicaid
INP00844293OtherRAILROAD MEDICARE
000000230225OtherANTHEM
IN200392780QMedicaid
ILL98357Medicare PIN
030005377OtherRAILROAD MCARE PALAMETTO
IN859910OOOOMedicare PIN
IN200392780Medicaid
IN859920SMedicare PIN
IN841040FFMedicare PIN
IN230650GMedicare PIN
IN265130YYYMedicare PIN